Elderly Care Needs Assessment

Name

Email

Telephone

Daily Living Activities - Bathing/Showering

Independently

With some help

Requires full assistance

Dressing

Independently

With some help

Requires full assistance

Toileting

Independently

With some help

Requires full assistance

Eating

Independently

With some help

Requires full assistance

Mobility (walking, transferring from bed/chair)

Independently

With some help

Requires full assistance

Household tasks (cleaning, laundry, cooking)

Independently

With some help

Requires full assistance

Health and Medical Needs - How would you describe your overall health?

Good, with no significant medical issues

Fair, with manageable medical conditions

Poor, with multiple or complex medical conditions

Do you require regular medication management?

No

Yes, but I manage it myself

Yes, I need assistance

Do you have any specific medical conditions that require ongoing care (e.g., diabetes, heart disease, dementia)?

No

Yes (Please Specify)

If Yes

Cognitive Function - How would you describe your memory and cognitive function?

Sharp and unaffected

Some minor memory lapses

Significant memory issues or cognitive decline

Do you ever feel confused or disoriented?

Rarely or never

Occasionally

Frequently

Social and Emotional Needs - How often do you engage in social activities?

Regularly

Occasionally

Rarely

Do you feel lonely or isolated?

No

Sometimes

Often

How important is it for you to be near family and friends?

Very important

Somewhat important

Not very important

Current Living Situation - Are you currently living alone?

Yes

No, with a spouse/partner

No, with family or caregivers

Is your current home accessible (e.g., no stairs, handrails, accessible bathroom)?

Yes

Partially

No

Are you able to maintain your home (e.g., cleaning, repairs)?

Yes, independently

Yes, with help

No

Financial Considerations - Do you have the financial resources to afford in-home care, assisted living, or a care home?

Yes, without concern

Yes, but with careful budgeting

No, financial assistance may be needed

Preferences for Care - Do you prefer to stay in your own home as long as possible?

Yes

No, I'm open to moving

What is most important to you in a care setting?

Independence

Social opportunities

Proximity to family

Quality of medical care

Comfort and amenities

0121 373 0200
enquiries@beechhillgrange.co.uk

Elderly Care Needs Assessment Survey

Assessment

Contact

0121 373 0200

enquiries@beechhillgrange.co.uk

Beech Hill Grange Care Home

0121 373 0200enquiries@beechhillgrange.co.uk

Elderly Care Needs Assessment Survey

Assessment

Contact

0121 373 0200

enquiries@beechhillgrange.co.uk

Beech Hill Grange Care Home

0121 373 0200
enquiries@beechhillgrange.co.uk